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S/GUM/clinic forms from May 2012/Self Assessment Forms/May 2012
INTEGRATED SEXUAL HEALTH
CARDIFF ROYAL INFIRMARY
PATIENT SELF ASSESSMENT AND REGISTRATION FORM
If you have attended the clinic before and been given a patient identification number
please write the number here if known……………………………………
Please Tick:
Male Female
Age…….. Date: …………………..
I am attending here because (ONLY TICK BOXES THAT APPLY TO YOU)
1. I would like a check up for STI’s – I have NOT noticed any problems (e.g. abnormal
discharge, lumps, rashes, itching, pain).
2. I would like a pregnancy test or contraception – please write below which type of
contraception if known:
………………………………………………………………………………………………………………
3. I ONLY
want an HIV test
4. I have had sex with someone who has told me they have HIV/AIDS
5. I have pain – abdominal /genital
6. I have noticed genital problems e.g. unusual vaginal or penile discharge, ulcers or warts
7. I have been asked to attend by this clinic or GP
8. A partner of mine has been found to have a sexually transmitted infection (other than genital
warts / genital herpes)
9. Is your partner attending the clinic with a problem today? If so please tick box
10. Other………………………………………………………………………………………………
PLEASE ANSWER YES / NO TO THE FOLLOWING QUESTIONS
a. Are you pregnant?
Yes
No
b. If you are a man have you had sex with another man?
Yes
No
c. Have you or any sexual partner ever injected drugs?
Yes
No
d. Have you ever had sex with someone who is not from the
UK?
Yes
No
If yes which countries……………………………………………………………………………………………
e. Have you ever paid for or been paid for sex?
Yes
No
f. Have you ever been in a relationship where you have
been hit or hurt in some way?
Yes
No
g. Are you currently in a relationship where this is happening
to you?
Yes
No
h. Have you attended this clinic before?
Yes
No
i. I am attending following a sexual assault Yes No